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ROSACEA THE BASICS:  

Marc Crupie MD 

Between the ages of thirty and fifty, millions of adults, many with English or Irish ancestry, notice increasing redness across their nose and cheeks. The redness may start as a tendency to flush easily, and it often persists as continual redness. This is most likely rosacea.
Some people call rosacea adult-onset acne, and it can look similar. Redness, bumps, and even some swelling appear well after adolescence. Some rosacea sufferers are even labeled as alcoholics because of their redness.

WHAT IS ROSACEA AND WHAT TRIGGERS IT?
Remember that you may have one or more causes for rosacea including some not listed here.

•Family history
•Alcoholic beverages
•Exercise
•Foods
•Beverages
•Weather
•Facial scrubs and skin care products
•Emotional Influences


 WHAT ARE THE POSSIBLE TREATMENTS?
We’re all individuals, so there may be variations in treatment depending on your particular needs. Here are some of the most common:

•Lifestyle changes
•Cleansers
•Prescription gels, lotions, and creams
•Oral antibiotics
•Accutane
•Lasers


WHAT IS ROSACEA?
Rosacea is often referred to as "adult acne." It may begin as a tendency to flush or blush easily and gradually progresses to persistent redness and occasionally swelling across the bridge of the nose and into the cheeks, forehead, and chin. As it progresses, small blood vessels, red bumps, pimples, and sometimes even larger cysts appear in the area. Unlike acne, there are no blackheads.
Initially, the redness of rosacea may come and go; you may not realize you need treatment. Sometimes rosacea appears as redness that doesn't go away.  If the skin doesn’t return to its normal color and enlarged blood vessels and pimples appear. Rosacea usually becomes worse without treatment and seldom goes away on its own.  We have many good treatments now and new ones emerging.
In more advanced cases of rosacea, a condition called rhinophyma may develop. The oil glands and the blood vessels on the nose enlarge so much that the nose becomes very bulbous in appearance. Thick bumps can develop on the nose and may require surgery to treat.
About half of the patients with rosacea have eye symptoms. Many experience some burning and grittiness of the eye (conjunctivitis) or inflammation and swelling of the eyelid areas.

Family history:

The most likely people to develop rosacea have an English or Irish background. You may get it even if your family genes are not Celtic or Northern European. Many rosacea sufferers are fair skinned, particularly women between the ages of 30 and 50, although rosacea also affects men and occasionally even teens. Researchers do not know why women get rosacea more often than men, and some cases have been associated with menopause. The key to successful management of rosacea is early diagnosis and treatment.

Rosacea Trigger Factors:
Rosacea can be triggered by multiple factors.  Many patients can reduce their redness by finding their triggers for redness. Two common triggers are alcohol and heat, but triggers range from soy to aged cheese and many more. Rosacea may cause redness in non-drinkers, some of those who suffer from rosacea have been falsely assumed of being alcoholics due to their facial vascularity and redness.
Triggers for rosacea may include alcohol (especially red wine, beer, bourbon, gin, vodka, or champagne), heat (saunas or hot tubs), sun, strong winds, exercise, coffee or other hot drinks, foods (liver, dairy products, chocolate, soy products, vegetables especially eggplants, tomatoes and beans, fruits including avocados, bananas and citrus fruits, hot and spicy foods), skin care products (particularly sprays containing alcohol fragrances or witch hazel), and overuse of prescription topical steroid creams.
Remember that rosacea is a disease that often starts in mid-life and can continue for 10 to 30 years. The little things that you do every day really do make a difference over that many years in the progression and treatment of this problem.
Think about your alcohol use. Some patients with rosacea find that they tolerate white wine or certain spirits easily, but that red wine, bourbon, gin, or vodka gives them a flushed look. If you enjoy an occasional drink or glass of wine, you might want to experiment with different types. For some people the sulfites used to preserve wine are the problem rather than the wine itself; try a sulfite-free wine. Inexpensive wines have more additives in general. Decrease your overall alcohol use. A glass of wine a day, particularly with a meal, may have beneficial effects on blood fat levels. But there can be problems with drinking more, beyond just causing your rosacea to flare.
Exercise:

Exercise in a cool environment, if possible, and try not to overheat more than necessary.
Foods:

Food triggers are very individual, and you might want to keep a food diary for several weeks to see if any foods aggravate your redness.
Beverages:

Try avoiding hot drinks and caffeine. Keep a log for a few weeks of when you’re flushing and if it’s associated with certain drinks. If there is no association, great, there’s no need to stop that beverage. If there is a beverage that’s causing problems, you may be able to find a substitute.
Weather

Practice good sun protection and avoid the extremes of hot and cold temperatures that aggravate symptoms of rosacea. Limit exposure to sunlight, wear a hat, and use broad-spectrum sunscreens with an SPF of 15 or higher in the winter and 30 or higher in the summer.
What about facial scrubs? 

Rubbing will tend to irritate reddened skin. Avoid rubbing, scrubbing, or massaging the face.
Skin and hair care products:

Try to avoid any type of hair spray product – use gels or creams instead. Avoid irritating cosmetics and facial products. Many rosacea patients don’t tolerate Renova/Retin-A/tretinoin very well. Creams with alpha hydroxy acids in high percentages may also be very irritating.
Emotional influences:

Stress and anxiety have been reported to aggravate rosacea in some. There are many good stress reduction programs and gentle forms of exercise that may be beneficial.
Do I Have Rosacea if I Flush and Blush Easily?

Almost everyone who goes on to get rosacea has a history of flushing and blushing. But just because you flush, it doesn’t mean you have rosacea. Many of us flush and blush, especially with exercise, heat, and stressful situations. The difference is that with early rosacea you might start to flush more and more frequently and with more triggers. The redness doesn’t seem to go away as easily and is a more permanent flush.

TREATMENTS:
Lifestyle Changes
The following list gives you some of the lifestyle changes that may help your redness, flushing and blushing, and rosacea.  Try these various changes one at a time. You’ll want to try the change for at least several weeks before you decide if it’s helping or not. Redness will often wax and wane over a period of weeks or months. If you try something only for a couple of days, you really can’t be sure if the change has made a difference or not. Some of the changes you might like to try are:

•Avoid alcohol completely or try different types of alcohol (try white wine instead of red to see if that makes a difference).
•If you live in a warm climate, exercise in indoor/outdoor spaces that are 70 degrees or less.
•Try avoiding spicy foods
•Avoid coffee and caffeinated teas.
•Avoid drinking hot liquids.
•If you have allergies, make sure that they’re treated and under control.
•If sun seems to activate your redness, try using zinc based sunscreens and staying out of the sun.
•If you think you might be peri-menopausal or menopausal, check with your doctor to see if estrogen replacement is advisable for other reasons as well.
•If you are pregnant, avoid getting overheated or overly fatigued.
•If you are on hormone replacement therapy already, try taking your estrogen at night instead of the morning.

Lifestyle changes really are one of the mainstays of rosacea treatment. The more effective you are at eliminating the things that trigger flushing, blushing, and rosacea breakouts, the more successful your physician will be with prescription treatments for your rosacea.

Is your rosacea is affected by your occupation?  Consider the case of the chef with severe rosacea. Her job required her to work in an overheated kitchen and to go to frequent wine tastings. Her rosacea can still be brought under control, but it takes more work.  Women between mid-40s and mid-50s having early symptoms of menopause may need extra treatment because menopausal hot flashes can aggravate rosacea and make it more difficult to control.

Cleansers
Mainly, it is important not to use cleansers that irritate rosacea.  You should stick to something like Dove for sensitive skin or Cetaphil Lotion Cleanser, but any gentle cleanser that doesn’t irritate you is okay.  There are many good choices for nonirritating, non-drying cleansers for rosacea. There is also a prescription cleanser called Plexion (contains sulfacetamide and sulfur) that may be helpful as well.
Wash your face twice a day with warm but not hot water. Hot water will aggravate the redness that goes with rosacea. Also avoid washing your face in a hot shower and avoid aiming the spray of your high-pressure showerhead at your face. After you wash your face with a non-irritating cleanser, pat it gently dry. When it is dry, apply any rosacea medications. Then if you still feel dry, you can add a gentle non-irritating moisturizer and sunscreen in the morning.
Avoid scrubs; they are too harsh for skin with active rosacea. Also, you may not tolerate the vitamin A derivatives like Renova/Retin-A/tretinoin or most alpha hydroxy acid or Vitamin C lotions or creams unless they are specifically formulated for sensitive skin.

THIS IS A LIST OF MY FAVORITE CLEANSERS - CREAMS ON THE MARKET TODAY.

Non-Prescription Creams
A newer non-prescription cream is Eucerin Red Reducer.  Another non-prescription cream that is used for redness or rosacea is hydrocortisone, which comes in either 0.5% or 1.0% cream. This cream is a very mild anti-inflammatory cream in the steroid category. It does reduce redness somewhat. However, it really does not address the root causes of rosacea at all. While hydrocortisone cream may make the redness or rosacea look temporarily a bit less red, it isn’t nearly as good as the treatments that are available by prescription.
Using a little hydrocortisone cream while you are waiting to get in to see your doctor is probably fine. But don’t use it over long periods of time or in lieu of the better prescription treatments that are available. Almost all steroid creams if used incorrectly can thin the skin and cause permanent dilation of blood vessels in the skin. Generally, hydrocortisone .5% and 1% are not strong enough to do that unless you use them many times a day over a long period of time. Don’t use them for long around the eye area under any circumstance.

Prescription Creams for Rosacea
Metronidazole is available in three forms: a cream, a lotion, and a gel also known respectively as Metrocream, Metrolotion, and Metrogel. These have been a staple for treatment of rosacea for many years. They are generally prescribed for use twice a day, although if your rosacea has been stable and inactive several months, cutting down to once a day might be fine. A relatively new cream called Noritate is also a metronidazole cream in a different strength and is used once a day. Sulfacetamide cream is another antibiotic cream used for treatment of rosacea. The azelaic acids are also being used with some good results for rosacea.  Azelex comes in a gel form and Finacea in a cream form.  Many other good topicals are available.  Whether you need a gel, lotion, or cream for your medication depends more on your underlying skin type than the fact that you have rosacea. If you have oily or acne-prone skin, you will probably prefer a gel, like Metrogel or Azalex. Many male patients seem to prefer the gel. If your skin is more normal or combination, the lotion will probably be most compatible. If you are dry or over forty, the creams would be good choices for you. There is another topical antibiotic that works well called sulfacetamide. It also comes in lotion and creams forms.

If you are quite red or have permanently dilated small blood vessels, the creams alone may not take the redness away. The topical medicines are excellent at helping to get the rosacea under control and helping to prevent recurrences particularly over the long haul. Unfortunately, you may be disappointed if you expect the topical medications to get rid of all the redness, particularly if it has been going on for a long time. If you have been red for a while you will probably need other treatment in addition. 

Oral Antibiotics for Rosacea
As part of your rosacea treatment, you may have been prescribed an oral antibiotic either continuously or intermittently during the course of the disease. Oral antibiotics help to decrease the acne-like pustules and pimples and decrease the inflammation that can cause swelling and redness.
A common treatment approach with new active rosacea is to start metronidizole cream twice a day in addition to an oral antibiotic for 60 days. It takes the antibiotic creams about 8 to 10 weeks to really work. The oral antibiotics take effect faster and then may be stopped once the cream has started to take effect.  You may have the type of rosacea that needs continual suppressive oral antibiotics for good control. Tetracycline, doxycycline, and minocycline are prescribed most commonly but other antibiotics may be used as well.
You should begin to see some improvement in one to three weeks with continued improvement slowly over several months. Antibiotics in the tetracycline (like doxycycline) family should not be taken by pregnant women or by women who are actively trying to get pregnant. They can also cause increased sensitivity to the sun, so ask about continuing their use if you plan to go on vacation in a sunny place.
Amoxicillin is an alternative in a woman who is past her third month of pregnancy and develops rosacea or in a woman who is trying to get pregnant. It is safe during pregnancy and has been used for many years.
Many physicians prescribed both oral and topical antibiotics at the beginning of treatment. The main reason for this is that it takes the topical antibiotic eight to twelve weeks to start working well. This is a long time to wait for many people who are anxious to get their rosacea under good control as quickly as possible. The oral antibiotics work much faster, and generally you should start to see results within a week or two.
One approach is to start both oral and topical medications and then stop the oral antibiotics after two to three months.  After that time it is often possible to maintain good control with the Metrocream alone. Another approach is to start with a metronidazole cream and if it isn’t working well after eight to ten weeks, then add an oral antibiotic. The most common oral antibiotics used for rosacea are tetracycline, doxycycline, and minocycline. Others may be used with good success, especially if you are allergic to tetracycline and its relatives.
Since the medicated creams and lotions may not control the rosacea one hundred percent of the time, it is often wise to keep some of the oral antibiotic on hand in case of a sudden flare-up of the rosacea. This seems to be most common around holiday times when perhaps more alcohol is consumed or dietary patterns interrupted. Another frequent time for flare-ups seems to be vacations, so be sure you take your medication when you go. Often a week or two of the antibiotic will suffice if the rosacea flare-up is caught early.

Accutane
Regular acne and acne rosacea are two very different diseases. In treating regular acne, Accutane should be reserved for patients who have severe cystic scarring acne or who have moderately severe acne that has not responded to reasonable trials of other types of therapy. Rosacea is a completely different story. It rarely is cystic, and it rarely scars. It does, however, work well in that occasional situation where rosacea has become cystic and is not responding to other treatment. Accutane is a potent medication with many potential side effects.  Birth defects are very real concern if you become pregnant while on Accutane.  It is safe to become pregnant two months after Accutane is discontinued.

When Should I Consider Getting Laser Treatments?
Since being red does not hurt, the answer is when it becomes a bother. Laser treatments for redness or dilated blood vessels are really a cosmetic issue. But it might be time to consider them if:

1 Your flushing is bad enough that it is interfering with your work or social life. For example, you’re avoiding speaking in public because you’re afraid you might flush or blush.

2 You have people assume that you’re a heavy drinker because your nose and cheeks are red.

3 You have to pile on the make-up in the morning just to feel presentable for work or play.

4 You have a strong family history of rosacea, and you know you’re probably going to get worse over the next several years.


"My rosacea is under good control with prescription medications, but I still seem to be red. Why isn’t this going away?"
There are a lot of causes for redness, rosacea being one of the main ones. Once the active rosacea is under good control, the baseline redness and dilated blood vessels may not go away with prescription medications alone. It is still important to keep using them though to keep the rosacea under control and prevent further progression of the disease. In this particular situation, the best way to remove the redness, dilated blood vessels and bring the skin back to its baseline color is to use gentle lasers to take the red out. Don’t undertake laser treatments though until your rosacea has been treated for at least two to four months. You don’t want to waste your money.
It is also important to know that, after you have finished your laser treatment for the redness and dilated blood vessels, that you will probably need periodic maintenance treatments to maintain your baseline color. The more you flush and blush or do other things that aggravate redness, like drinking wine or spending time in the heat or sun, the more often maintenance treatments will probably be needed.

SUMMARY OF ROSACEA: WHAT TO DO
Rosacea is a disease that often gets worse if you don’t do anything about it, to help prevent progression and get the rosacea under control, use gentle cleansers, sunscreens and moisturizers.  Have a lifestyle that avoids or minimizes triggers and use prescription creams or antibiotics. Once your rosacea is treated and under control, you may want to consider having one of the gentle laser treatments to reduce the remaining redness and/or dilated blood vessels.